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Training Nomination Form 2018

The document is a nomination form for a training course organized by the International Atomic Energy Agency (IAEA). It requires personal information, contact details, language skills, education, work experience, health status, and previous participation in IAEA activities from the nominee. Additionally, it includes sections for government approval and privacy data sharing, ensuring compliance with IAEA policies.

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valiyevsahil01
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6 views

Training Nomination Form 2018

The document is a nomination form for a training course organized by the International Atomic Energy Agency (IAEA). It requires personal information, contact details, language skills, education, work experience, health status, and previous participation in IAEA activities from the nominee. Additionally, it includes sections for government approval and privacy data sharing, ensuring compliance with IAEA policies.

Uploaded by

valiyevsahil01
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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International Atomic Energy Agency (IAEA)

Vienna International Centre, PO Box 100, 1400 Vienna (Austria)


Tel: (+43 1) 2600, Fax: (+43 1) 26007, Email: [email protected], TC website: https://www.iaea.org/technicalcooperation/

NOMINATION FOR TC TRAINING COURSE


The Government (nominating authority) of
Nominates the person indicated below for the following event organized under TC project
Event title:
Location:
Date(s): YYYY-MM-DD - YYYY-MM-DD
1. PERSONAL INFORMATION (As per passport)
Gender: ☐ Female ☐ Male Nationality:

Last name: 2nd nationality (if any):

Middle name (if any): Passport No.:

First name: Date of issue: YYYY-MM-DD

Date of birth: YYYY-MM-DD Place of issue:

Place of birth: Date of Expiry: YYYY-MM-DD

2. CONTACT DETAILS
Institute name:
Institute address:
Postal Code:
City:
State:
Country:
Telephones (including country/city codes):
Preferred Number:
Alternate Number 1:
Alternate Number 2:
Preferred email:
Alternate email:
Airport/town nearest to residence:
3. LANGUAGE SKILLS

Mother tongue: Description:


Language: Proficiency: FLUENT (F) Speak, read and write nearly as well as
mother tongue
WORKING KNOWLEDGE Engage freely in discussions, read and write
(W) more complex material
LIMITED (L) Limited conversation, reading of
newspapers, routine correspondence

4. EDUCATION
Start date - End date YYYY/MM – YYYY/MM
Institution:
City, Country:
Education level:
Field of study:
Start date - End date YYYY/MM – YYYY/MM
Institution:
City, Country:
Education level:
Field of study:

(TCPC-July 2021)
Start date - End date YYYY/MM – YYYY/MM
Institution:
City, Country:
Education level:
Field of study:
5. WORK EXPERIENCE
Current job: ☐ Yes ☐ No
Start date - End date YYYY/MM – YYYY/MM
Employer:
City, Country:
Job Function:
Title of Position:
Description of Duties:

Current job: ☐ Yes ☐ No


Start date - End date YYYY/MM – YYYY/MM
Employer:
City, Country:
Job Function:
Title of Position:
Description of Duties:

Current job: ☐ Yes ☐ No


Start date - End date YYYY/MM – YYYY/MM
Employer:
City, Country:
Job Function:
Title of Position:
Description of Duties:

6. HEALTH AND RADIATION


I declare that I am in good health, free from infectious diseases and able physically and mentally to carry out any relevant
duties away from home.
☐ Yes ☐ No
If you have a physical disability or medical condition which might limit your ability to perform your assignment, please
indicate the limitations below:

A medical certificate of good health signed by a registered medical practitioner dated not more than four months prior to the
event must be submitted for:
• events with a duration exceeding one month;
• all candidates over the age of 65 regardless of the event duration.
Are you covered under a radiation surveillance programme in your country?
☐ Yes ☐ No
Please provide the dose records for Please provide:
the past five years. • A medical certificate or personal declaration of health fitness to work with ionizing
radiation;
• Information on your training in radiological protection;
• The dose records of the past five years (if available).
Radiation Surveillance Remarks:

7. DESCRIPTION OF WORK
Past work done by the nominee which is relevant to the event:

8. PREVIOUS PARTICIPATION IN IAEA ACTIVITIES


Have you been or will you be involved in any IAEA activity?: ☐ Yes ☐ No
If yes, please list each activity below:
9. PRIVACY AND DATA SHARING
Participants are hereby informed that the personal data they submit will be processed in line with the Agency’s Personal Data
and Privacy Policy and is collected solely for the purpose(s) of reviewing and assessing the application and to complete
logistical arrangements where required. Further information can be found in the Data Processing Notice concerning IAEA
InTouch+ platform. By signature of this form, I confirm that I have read and agree to the Data Processing Notice.
10. OBJECTIVES FROM THE GOVERNMENT’S POINT OF VIEW
How is the Government going to make use of the training received by the candidate at the course?

11. COUNTRY APPROVAL


The nominating authority gives the following assurances:
• All information supplied in this form is complete and correct, and the applicant is proficient in the training language;
• Should the candidate’s language qualification prove to be insufficient or should the candidate’s state of health not
correspond to the examining physician’s statement, the nominating authority will accept the responsibility for the
consequences and any costs arising therefrom;
• It is noted that the sponsoring organization(s), host country(ies) and host institution(s) do not accept liability for the
payment of any costs or compensation arising from damage to or loss of personal property, or from illness, injury,
disability or death of a participant while he/she is travelling to and from or attending the training course and it, the
nominating authority, undertakes the responsibility for such coverage;
• The position of the nominee will be retained for him/her and he/she will continue to receive during the training a salary
and related emoluments to enable him/her to meet his/her financial commitments in his/her home country;
• If selected, the nominee will conduct himself/herself in a manner compatible with his/her status as a participant in an
IAEA event and will refrain from engaging in any political and commercial activities;
• No facts are known to the nominating authority regarding the reliability and character of the nominee which would
obstruct giving him/her access to nuclear installations or institutions where ionizing radiation is used.

SIGNATURE OF APPLICANT NAME: DATE: YYYY-MM-DD

SIGNATURE OF COUNTERPART NAME: DATE: YYYY-MM-DD

SIGNATURE OF NLO NAME: DATE: YYYY-MM-DD

Important: Please attach a copy of your passport (or other ID if no passport exists)!

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